Palliative Transcatheter Arterial Chemoembolization for Relieving Metastatic Bone Pain due to Hepatocellular Carcinoma: A Case Report

Bone metastasis is the third most common extrahepatic metastasis from hepatocellular carcinoma (HCC), following lung and lymph node metastasis. Although transcatheter arterial chemoembolization (TACE) is widely used for the treatment for unresectable HCC in the liver, its effects on bone metastasis from HCC have not been well described in past literature. We report a case of a patient with a metastatic bone lesion from an HCC treated with TACE. After the procedure, the patient's pain and narcotic requirement significantly decreased without major complications.

Perfusion CT in Colorectal Cancer: Comparison of Perfusion Parameters with Tumor Grade and Microvessel Density

OBJECTIVE: The purpose of this study was to prospectively compare pre-operative computed tomography (CT) perfusion parameters with tumor grade from colorectal adenocarcinoma (CRC) and to correlate pre-operative CT perfusion parameters with microvessel density (MVD) to evaluate angiogenesis in CRC. MATERIALS AND METHODS: Pre-operative perfusion CTs were performed with a 64-channel multidetector row CT in 27 patients (17 women and 10 men; age range 32-82 years) who were diagnosed with CRC involving the sigmoid and rectum between August 2006 and November 2007. All patients underwent surgery without pre-operative chemotherapy or radiation therapy. Dynamic perfusion CTs were performed for 65 seconds after intravenous injection of contrast medium (100 mL, 300 mg of iodine per mL, 5 mL/sec). Before surgery, blood flow (BF), blood volume, mean transit time (MTT), and permeability-surface area product were measured in the tumor. After surgery, one gastrointestinal pathologist evaluated tumor grade and performed immunohistochemical staining using CD 34 to determine MVD in each tumor. The Kruskal-Wallis test was used to compare CT perfusion parameters with tumor grade, and Pearson's correlation analysis was used to correlate CT perfusion parameters with MVD. RESULTS: In 27 patients with CRC, tumor grading was as follows: well differentiated (n = 8); moderately differentiated (n = 15); and poorly differentiated (n = 4). BF was higher in moderately differentiated CRC than well differentiated and poorly differentiated CRCs (p = 0.14). MTT was shorter in moderately differentiated than well differentiated and poorly differentiated CRCs (p = 0.039). The MVD was greater in poorly differentiated than well differentiated and moderately differentiated CRCs (p = 0.034). There was no significant correlation between other perfusion parameters and tumor grade. There was no significant correlation between CT perfusion parameters and MVD. CONCLUSION: BF and MTT measurement by perfusion CT is effective in predicting moderately differentiated CRCs. However, perfusion CT is limited in distinguishing well differentiated and poorly differentiated CRCs. Pre-operative perfusion CT does not reflect the MVD of CRCs.

Effect of Ultrasound-Guided Radiofrequency Ablation in Incompletely Treated Hepatocellular Carcinoma after Transcatheter Arterial Chemoembolization

OBJECTIVE: To evaluate the effectiveness of ultrasound-guided radiofrequency (RF) ablation in patients with incompletely treated hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) and to evaluate possible prognostic factors for this therapy. SUBJECTS AND METHODS: Thirty nine patients with incompletely treated single HCC ( 2 cm) was statistically significant in terms of predicting local recurrence. Complications were observed in two patients, one with liver abscess and the other with portal venous thrombosis. CONCLUSION: Ultrasound-guided RF ablation could be effective and safe in treating incompletely treated HCC after TACE. The diameter of HCC was a significant prognostic factor for local recurrence.

Retrograde Tempofilter II(TM) Placement within the Superior Vena Cava in a Patient with Acute Upper Extremity Deep Venous Thrombosis: the Filter Stands on Its Head

The Tempofilter II is a widely used temporary vena cava filter. Its unique design, which includes a long tethering catheter with a subcutaneous anchor, facilitates the deployment and retrieval of the device. Despite this, the Tempofilter II has been used only in the inferior vena cava of patients with lower extremity deep venous thrombosis. In this article, we present a case of superior vena cava filtering using the Tempofilter II in patients with upper extremity deep venous thrombosis.

Fracture of a Tempofilter II: an Initial Case Report

Tempofilter II is a device that is used for pulmonary embolism prophylaxis. Since the appearance of the Tempofilter II following withdrawal of the Tempofilter I, it has been reported that the Tempofilter II is safe, effective and useful. Here we report on the first case of a fracture of one leg of the filter and this leg was embedded in the inferior vena cava wall in a 62-year-old man with deep vein thrombosis.

Selective embolization of the internal iliac arteries for the treatment of intractable hemorrhage in children with malignancies / 소아과

PURPOSE: Acute internal hemorrhage is an occasionally life-threatening complication in pediatric cancer patients. Many therapeutic approaches have been used to control bleeding with various degrees of success. In this study, we evaluated the efficacy of selective internal iliac artery embolization for controlling acute intractable bleeding in children with malignancies. METHODS: We retrospectively evaluated the cases of 6 children with various malignancies (acute lymphoblastic leukemia, acute myelogenous leukemia, chronic myelogenous leukemia, T-cell prolymphocytic leukemia, Langerhans cell histiocytosis, and rhabdomyosarcoma), who had undergone selective arterial embolization (SAE) of the internal iliac artery at the Chonnam National University Hwasun Hospital between January 2004 and December 2009. SAE was performed by an interventional radiologist using Gelfoam(R) and/or Tornado(R) coils. RESULTS: The patients were 5 boys and 1 girl with median age of 6.9 years (range, 0.7-14.8 years) at the time of SAE. SAE was performed once in 4 patients and twice in 2, and the procedure was unilateral in 2 and bilateral in 4. The causes of hemorrhage were as follows: hemorrhagic cystitis (HC) in 3 patients, procedure-related internal iliac artery injuries in 2 patients, and tumor rupture in 1 patient. Initial attempt at conservative management was unsuccessful. Of the 6 patients, 5 (83.3%) showed improvement after SAE without complications. CONCLUSION: SAE may be a safe and effective procedure for controlling acute intractable hemorrhage in pediatric malignancy patients. This procedure may obviate the need for surgery, which carries an attendant risk of morbidity and mortality in cancer patients with critical conditions.

Investigation of Prophylactic Antibiotic Usage for Interventional Radiology in Korea / 감염과화학요법

Every interventional procedure can result in infectious complication even though its incidence is very low. Increases in both indication of procedures and number of immunocompromised patients are likely to result in increase of infectious complications. However, no randomized controlled trials to evaluate the effectiveness of prophylactic antibiotics in interventional procedures have ever been performed. This study was performed to investigate the actual pattern of practice and awareness of medical providers concerning the antibiotic prophylaxis following vascular and nonvascular interventional procedures. A questionnaire regarding prophylactic antibiotic usage was sent to the interventional radiologists in 40 hospitals. A total of 12.2-30.3% responders used prophylactic antibiotics for vascular procedure. More than 80-90% of responders answered that vascular procedures except catheter insertion, are not clear indications of prophylactic antibiotics. In contrast, 31.3% and 51.5% of responders used prophylactic antibiotics for genitourinary and biliary drainage respectively. About 60-70% of responders considered both genitourinary and biliary drainage as clear indications of antibiotic prophylaxis. Further study assessing the appropriate antibiotic usage in interventional procedures is warranted.

Investigation of Prophylactic Antibiotic Usage for Interventional Radiology in Korea / 감염과화학요법

Every interventional procedure can result in infectious complication even though its incidence is very low. Increases in both indication of procedures and number of immunocompromised patients are likely to result in increase of infectious complications. However, no randomized controlled trials to evaluate the effectiveness of prophylactic antibiotics in interventional procedures have ever been performed. This study was performed to investigate the actual pattern of practice and awareness of medical providers concerning the antibiotic prophylaxis following vascular and nonvascular interventional procedures. A questionnaire regarding prophylactic antibiotic usage was sent to the interventional radiologists in 40 hospitals. A total of 12.2-30.3% responders used prophylactic antibiotics for vascular procedure. More than 80-90% of responders answered that vascular procedures except catheter insertion, are not clear indications of prophylactic antibiotics. In contrast, 31.3% and 51.5% of responders used prophylactic antibiotics for genitourinary and biliary drainage respectively. About 60-70% of responders considered both genitourinary and biliary drainage as clear indications of antibiotic prophylaxis. Further study assessing the appropriate antibiotic usage in interventional procedures is warranted.

Tracking of Neural Stem Cells in Rats with Intracerebral Hemorrhage by the Use of 3T MRI

OBJECTIVE: To access the feasibility of clinically available 3T MRI to detect the migration of labeled neural stem cells (NSCs) in intracerebral hemorrhage (ICH) in a rat model. MATERIALS AND METHODS: The ethics committee of our institution approved this study. ICH was induced by the injection of collagenase type IV into the right striatum of ten Sprague-Dawley rats. Human NSCs conjugated with Feridex (super-paramagnetic iron oxide: SPIO) were transplanted into the left striatum one week after ICH induction. MRI was performed on a 3T scanner during the first, second, third, fourth, and sixth weeks post-transplantation. MRI was obtained using coronal T2- and T2*-weighted sequences. Two rats were sacrificed every week after in vivo MRI in order to analyze the histological findings. RESULTS: ICH in the right striatum was detected by MRI one and two weeks after transplantation without migration of the NSCs. There was no migration of the NSCs as seen on the histological findings one week after transplantation. The histological findings two weeks after transplantation showed a small number of NSCs along the corpus callosum. On MRI three weeks after transplantation, there was a hypointense line along the corpus callosum and decreased signal intensity in the right periventricular region. Histological findings three weeks after transplantation confirmed the presence of the hypointense line representing SPIO-labeled NSCs. MRI four and six weeks after transplantation showed a hypointense spot in the right periventricular region. The histological findings four and six weeks after transplantation showed the presence of prominent NSCs in the right periventricular region. CONCLUSION: 3T MRI can detect the migration of NSCs in rats with ICH along the corpus callosum. Therefore, 3T MRI could be feasible for detecting the migration of NSCs in the clinical setting of stem cell therapy.

Endovascular Stent Placement for the Treatment of Superficial Femoral Artery Stenoses and Occlusions

PURPOSE: The aim of this study was to evaluate effectiveness of an endovascular stent placement in the treatment of superficial femoral artery stenoses and occlusions. MATERIALS AND METHODS: An angioplasty and stent placement was performed in forty four patients (42 men and 2 women; mean age: 71.2 years; age range: 50-82 years). A total of 27 patients were diagnosed with intermittent claudication, in addition to 8 patients with resting pain, and 9 patients with gangrene. A follow-up evaluation accompanied with a physical examination, catheter angiography, and a color Doppler sonography was performed. The patency rates were analyzed after 3 months, 6 months, 1 year and 2 years. The predictors of restenosis, according to the clinical and anatomical classification, risk factors, as well as the correlation of stent fracture and restenosis were analyzed. RESULTS: Initial technical success was achieved in all patients. The stent placement resulted in an initial improvement of the clinical category in more than one level for 95.5% of cases. Over the course of the follow-up period (mean: 17 months; range, 1-106 months), restenosis occurred in 16 patients (36.4%). The highest patency rates were 87.9% after 3 months, 81.5% after 6 months, 78.0% after 1 year, 54.2% after 2 years, and 46.0% after 3 years. No significant difference was found for the patency rates as a function of the clinical and anatomical classifications, or the risk factors. A stent fracture was identified on only two occasions; however, no clinical symptoms or good intra-stent blood flow was observed in a follow-up angiography. CONCLUSION: A mid-term patency after the stent placements for superficial femoral artery stenoses and occlusions was found to be unfavorable despite an initial success rate. Consequently, greater clinical experience and analysis is necessary.

Efficacy of US-guided Hydrostatic Reduction in Children with Intussusception

PURPOSE: To assess the success rate and efficacy of US-guided hydrostatic reduction in children with intussusception. MATERIALS and METHODS: We retrospectively evaluated the ultrasonographic findings and clinical features of 121 children (M:F=80:41, mean age= 18 months) who underwent US-guided hydrostatic reduction between November, 2002 and February, 2007 for the diagnosis and treatment of intussusception. RESULTS: The 121 patients underwent 147 procedures, including recurred cases. Successful reduction was achieved in 132 cases (89.8% success rate), as confirmed by post-procedure ultrasonography and clinical findings. Emergency operations were performed in the 10 (6.8%) cases of irreducible intussusceptions, 8 of ileocolic type and 2 of ileoileal type. Perforation occurred in 4 cases (2.7%), and seizure in 1 case during the procedure (0.7%). CONCLUSION: US-guided hydrostatic reduction is a safe and effective tool for the diagnosis and treatment of pediatric intussusception.

The Histopathologic Reaction of Rabbit Lungs after Intrabronchial Application of Contrast Agents

PURPOSE: The aim of this study was to determine a safe gastrointestinal contrast agent that could be used in various clinical situations where there is a risk of aspiration using a rabbit model. MATERIALS AND METHODS: 30 healthy white rabbits were used. The rabbits were divided into 5 groups containing six animals each, one control group (anesthesia only) and 4 groups receiving various contrast agents [Solotop (Barium sulphate suspension), Gastrografin (Sodium and meglumine amidotrizoate), and Telebrix (Meglumine ioxitalamate), Visipaque (Iodixanol)]. The contrast agents were injected selectively into a main bronchus via a catheter inserted under fluoroscopy guidance. The rabbits were sacrificed either 1 day or 7 days after injecting the contrast agents, and the tissue reaction of the bronchi and lungs were examined both macro- and microscopically. The level of alveolar septal thickening, peribronchiolar lymphocytic infiltration, pulmonary congestion and edema, inflammatory exudate in the alveoli or bronchiolar lumina, microabscess formation, necrosis, pigmentation of materials injected, and fibropurulent pleurisy were evaluated and graded according to the severity as follows: no change, mild, moderate, marked in degree. RESULTS: The common microscopic findings were alveolar septal thickening and peribronchiolar lymphocytic infiltration. Pulmonary congestion and edema, inflammatory exudate in the alveoli or bronchiolar lumina were observed in 21 out of 24 rabbits receiving the contrast agents. Pigmentation of the materials injected was observed only in the group receiving Solotop. An inflammatory exudate in the alveoli and bronchiolar/bronchial lumina, microabscess formation, and necrosis were noted in most groups, but was more frequent and severe in the group receiving Gastrografin. CONCLUSION: The histopathological reactions of the rabbit lungs after the intrabronchial application of a contrast agent showed variable degrees of inflammatory reactions. Gastrografin produced most severe and extensive reaction, Solotop and Telebrix a moderate reaction, and Visipaque a minimal reaction. Therefore, a non-ionic dimeric contrast agent such as Visipaque may be the safest contrast agent in the lung when a GI tract examination is performed in clinical situations where there is a risk of aspiration.

Evaluation of Newly Developed Small (< or = 20 mm) Enhancing Nodules on the Arterial Phase CT after Transcatheter Arterial Cheomoembolization in Patients with Hepatocellular Carcinoma

PURPOSE: We assessed the clinical significance of newly developed small (< or = 20 mm) early-enhancing hepatic nodules on arterial phase CT after performing transcatheter arterial cheomoembolization (TACE) in patients suffering with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: We searched for the radiologic reports that showed small early enhancing nodule (< or = 20 mm) on the arterial phase imaging of follow-up CT after performing TACE. Thirty-seven lesions in 30 patients had round or oval shaped nodules and the numbers of nodule for one patient was less than five. We classified the nodules by size, location and the decreased attenuation seen on the portal venous phase. The latest follow-up CTs were reviewed to assess the nodules for the final diagnosis. All the follow-up CTs were two-phase spiral CT scans. RESULTS: Twenty-five (67%) of the 37 nodules were recurred HCC, as was determined on the basis of their interval growth and lipiodol uptake after TACE. Among the 37 nodules, seven (18%) disappeared on the latest follow-up CT and they were considered as definite pseudolesions. The remaining five (15%) were stable in size or they decreased in size, and they were considered as probable pseudolesions. The mean size of the nodules on initial CT was 11 mm. The mean size of the malignant nodules was 11+/-4.2 mm and that of the benign pseudolesions was 9+/-4.9 mm. The nodules located on the hepatic surface were possible to definite benign pseudolesions (p<0.05). All ten low attenuated nodules seen on the portal phase were HCCs. CONCLUSION: When seen on the follow-up CT scans of HCC patients after performing TACE, the newly developed small early-enhancing nodules were considered to have high potential of being HCC by their locations and enhancing patterns.

Hepatic Perfusion Disorders: A Pictorial Review of CT and MR Imaging

The liver has a unique dual blood supply through the portal vein and the hepatic artery. There are several communications between these two vessels under various conditions such as in hepatic tumors, trauma and liver cirrhosis, vascular compromise, among others. When vascular compromise occurs, this dual blood supply system can cause changes in the volume of blood flow in individual vessels or even in the direction of blood flow. With rapid image acquisition and increased resolution available in multislice CT and MR imaging, hepatic perfusion disorders are now more frequently encountered than in the past. Familiarity with imaging findings of these perfusion disorders will be helpful in characterizing focal hepatic lesions and will also help to avoid false positive diagnoses.